Prior authorization for inpatient mental health care and addiction and recovery treatment
Inpatient mental health treatment
Kaiser Permanente requires prior authorization of inpatient mental health care for all members, including members using their out-of-network benefits and members who do not want their care managed by Kaiser Permanente. Prior authorization assures Kaiser Permanente that the services are medically necessary and appropriate, that the provider and/or facility is fully licensed and capable of providing the highest level of care and allows Kaiser Permanente to plan for adequate follow-up care.
Prior authorization is not required for admission for emergency care. However, the care must meet medical necessity criteria. If a member is admitted to inpatient treatment as a direct result of an emergency room visit, the member or a family member must call the Kaiser Permanente Emergency Notification Line within 24 hours following the emergency or as soon as medically possible. You can obtain authorization after the health plan reviews clinical information, normally provided by the treating provider.
Inpatient addiction and recovery treatment
2021 brought changes to the prior authorization process regarding inpatient and residential services for addiction and recovery treatment. Per ESHB 2642, the following guidelines apply to acute inpatient and residential treatment for addiction and recovery:
- Regarding acute withdrawal management, members are eligible for 3 covered days of treatment without prior authorization. After the initial 3 covered days, ongoing care is subject to medical necessity criteria. If a member is admitted to acute withdrawal management, the member or a family member must call the Kaiser Permanente Emergency Notification Line within 24 hours following the admission or as soon as medically possible. For subacute withdrawal treatment you should obtain prior authorization.
- Regarding residential substance use disorder treatment, members are eligible for 2 covered days of treatment without prior authorization. After the initial 2 covered days, ongoing care is subject to medical necessity criteria. If a member is admitted, the member or a family member must call the Kaiser Permanente Emergency Notification Line within 24 hours following the admission or as soon as medically possible. While members with an out-of-network benefit may choose from which facility to receive service, their planned inpatient stay must be authorized prior to admission.
- We will continue to cover only medically necessary residential treatment for substance use disorders for people with comprehensive benefits for substance abuse services, following prior authorization.
- While we do not require prior authorization for PPO health plan members, we do require proof of medical necessity. A provider or member may request a benefit advisory. To ensure coverage eligibility, member can request prior authorization before entering treatment.
Contact the Mental Health Access Center (MHAC) at 1-888-287-2680 (206-901-6300) during regular work hours to obtain a prior authorization for inpatient mental health or substance use services.
Authorizations are not provided after-hours, on holidays, or on weekends. In these cases, contact EPRO (Emergency Patient Resources and Options) at 1-800-337-3197 (24/7 access) to inform Kaiser Permanente of admission. The MHAC will review on the next business day.
Contact the Provider Assistance Unit at 509-241-7206 or 1-888-767-4670 for questions about a member's health plan benefits.
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